SCOPE OF ROLE 

The Claims Analyst assists with oversight of claims processing, verifying information on submitted claims, reviewing the policy to determine which charges are eligible for reimbursement, auditing any vendor processed claims.  They ensure all business rules set by Bright Health Plan are followed by vendors and that payments are made according to CMS guidelines, Bright Contract and plan benefit designs. The Claims Analyst participates in audits, coordinating with Compliance and Legal to ensure Bright Health Plan provides all the requested data, navigate systems as needed during audit and provide any follow up requested by auditors.

ROLE RESPONSIBILITIES

The Claim Analyst job description is intended to point out major responsibilities within the role, but it is not limited to these items.

• Partner with Configuration, Provider Data, Network and vendors to ensure claims are paid to providers and members accurately.
• Monitor policies and procedures for Bright Health with claims.
• Monitor daily reporting distributed by vendors (claim reports, document aged reports)
• Provide recommendations on the design of claim payment system configuration.
• Serve all stakeholders through continuous monitoring and auditing of claim processing, educational and problem-solving support
• Handle adverse and politically difficult situations, as payment accuracy has a significant impact on the financial performance of the organization and our providers, processes related to claims processing, managed care negotiations along with directly impacting the financial performance of Bright Health Plan
• Read, interpret, and formulate complex computer system rules and managed care reimbursement payment methodologies including but not limited to CMS payment rules and requirements.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s degree in Business Administration or related field required.
• 3-5 years of experience in Enrollment, Premium Billing, Claims, Member and Provider Service, and Appeals at a health insurance company will be considered in lieu of a degree.
• 3-5 years of experience in commercial facility and professional pricing methodologies (DRG, case rate, per diem, % of billed, fee schedule, etc.) and application of CMS billing guidelines required.
• 3-5 years of health care systems and inter/intra-relationships specific to value-based contracting activities required.
• 3-5 years of complex managed care concepts/processes, and health insurance pricing and associated benefit design knowledge required.
• Intermediate or advanced Excel skills for data analysis required.

PROFESSIONAL COMPETENCIES

• Able to create and maintain strong working relationships.
• Complex problem-solving skills.
• Able to manage resources in a matrix environment, communicating and influencing effectively at all levels of the organization.
• Effective at vendor negotiations and relationship management.
• Broad knowledge of health insurance and services delivery and functions.
• In-depth knowledge of federal, state and CMS based requirements and the ability to develop, distribute and administer Medicare programs in a compliant manner.
• Success managing multiple initiatives and priorities simultaneously.
• Able to quantify impact and ROI of initiatives.
• Experience in government programs including Exchanges, Medicare and/or Medicaid.
• Experience with integrating health plan support services and other elements of operations in high-growth environment.
• Certified commercial medical billing coder a plus

WORK ENVIRONMENT

• The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
• Travel may be required.